INITIAL COMMENTS
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This report is a result of an onsite licensure renewal inspection. The inspection was conducted on November 19-20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Northwestern Human Services of PA - Susquehanna Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of employee training records and an interview with the facility director, the facility failed to provide documentation verifying that the project director had obtained 12 hours of training for the 2010-2011 training year.
The finding included:
The training records for the project and facility directors were reviewed during the November 19-20, 2012 renewal inspection.
Employee # 2, the Project Director accepted that position in October 2010. The training record did not include verification of the training the Project Director was listed as receiving on the "Staffing Requirements Facility Summary Report" for the 2011-2012 training year.
The Facility Director verified that no verification of training was available at the time of the inspection. The findings were not disputed.
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Plan of Correction
0075
During this past licensure year Susquehanna Center's project director provided Susquehanna Center with a list of seminars/trainings he had attend through the year however verification of attendance was not included. We have informed the office of the Project Director of this problem and requested his Office provide attendance sheets/ sign-in sheets or certificates of completion for a minimum of 12 hours of seminars/trainings he has attended each training year. These items will be collected on a quarterly basis from the Project Director's Administrative Support personnel.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the results of a physical plant inspection the facility failed to ensure that counseling sessions could not be seen or heard from outside the counseling room.
The finding included:
A physical plant inspection was conducted on the morning of November 19, 2012. The facility had 7 individual counseling offices and 3 group rooms. Each area has a solid wooden door with a narrow window in it. The windows were not covered on any of these doors, allowing counseling sessions to be seen from outside the counseling room.
The finding was reviewed with the facility director who did dispute the finding, but disagreed with the citation.
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Plan of Correction
P189
During our yearly inspection we received a citation for having narrow windows in the doors of our counseling offices and group rooms. Susquehanna Center's Staff 1 spoke with the head of NHS's maintenance Department and he has agreed to place a privacy stencil on the door windows which will prevent anyone from seeing in the counseling offices and group rooms. He indicated he would have this completed by the 2nd week in January 2013. Following completion of this project the local County Director will conduct an onsite inspection to insure compliance.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of staff training records, the facility failed to document that each employee received the mandatory training in emergency procedures upon hire for each employee.
The findings included:
Employee training records were reviewed on November 19, 2012 as part of the annual onsite licensure renewal inspection conducted November 19 & 20, 2012. Eight employee records were reviewed. Five of eight records failed to include documentation of staff training in emergency procedures.
Employee # 4 was hired on 9/11/12. There was no documentation of emergency procedure training for this employee as of 11/20/12.
Employee # 5 was hired on 6/23/99. There was no documentation of emergency procedure training for this employee as of 11/20/12.
Employee # 6 was hired on 5/23/11. There was no documentation of emergency procedure training for this employee as of 11/20/12.
Employee #7 was hired on 5/16/11. There was no documentation of emergency procedure training for this employee as of 11/20/12.
Employee # 8 was hired on 11/22/10. There was no documentation of emergency procedure training for this employee as of 11/20/12.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
P277
NHS Susquehanna Center has developed new procedures for Fire Safety for our new facility and the program Director will conduct a mandatory staff training regarding these procedures and employee assignments. This training will be completed on January 16, 2013, the date of our next scheduled staff meeting. The training will be documented in each employee's annual training record. In addition, this training will be done along with Fire Extinguisher training during the first week a new employee is at the Anthra Plaza facility. This training will be conducted by one of the following: Program Director, Clinical Supervisor or Office Manager. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to post a fee schedule in a prominent place as required.
The finding included:
A physical plan inspection was conducted on the morning of 11/19/2012 as part of the annual onsite licensure renewal inspection. At that time no fee schedule was posted in the facility. An interview with the facility director verified that no fee schedule was posted from the time of the move to the new facility in February 2012.
The finding was reviewed with the facility director and was not disputed.
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Plan of Correction
0171
Susquehanna Centers Fee scheduled was posted in our waiting room prior to the conclusion of the inspection. It is in hanging in the waiting room next to our Licenses.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that all disclosures of client identifying information were authorized by a valid informed consent to release information form signed by the client in each client record reviewed.
The finding included:
The annual onsite licensure renewal inspection was conducted November 19-20, 2012. Ten client records were reviewed on 11/20/2012. Six of ten client records reviewed did not have valid informed consents to release information documented at the time of the record review.
Client record # 1- This client was admitted on 7/25/12 and last treated on 11/6/12. Consents to release information in the record signed by the client on 7/25/12 for emergency contacts failed to identify the specific information to be released. A consent to release information form for a managed care organization for funding was signed by the client on 10/24/12 and failed to include documentation of the specific information to be released.
Client record #2 - This client was admitted on 9/11/12 and last treated on 11/2/12. A consent to release information to a managed care company, signed by the client on 9/11/12, failed to identify the specific information to be released or the purpose for the release of information. Consents to release information forms for emergency contacts signed by the client on 9/11/2012 and 9/28/2012 failed to identify the specific information to be released. A consent to release information to an area hospital signed by the client on 9/11/12 failed to identify the specific information to be released. Releases of information to a third party payer in letters dated 9/21/12, 10/6/12 and 11/3/2012 were carried out without the client's written consent.
Client record # 3- This client was admitted on 7/30/12 and last treated on 11/2/12. A letter was sent to a third party payer releasing client identifying information without the client's written consent.
Client record # 4 - This client was admitted on 5/24/12 and was discharged on 7/13/12. A consent to release information form for an emergency contact was signed by the client on 5/24/12, but the written consent failed to identify the specific information to be released.
Client record # 5- This client was admitted on 5/24/12 and last treated on 8/7/12. The record contained documentation of a signed consent to release information form dated 5/24/12 for emergency contacts, but the written consent failed to identify the specific information to be released.
Client record # 7- This client was admitted on 10/25/12 and last treated on 11/14/12. Letters containing client identifying information were mailed to a third party payer on 6/26/12, 10/4/12 and again on 10/14/12, without the client's written consent.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
0277
Mandatory training regarding the proper procedure for completing the ROI form with emphasis on what information can be released will be conducted by the program director following the fire safety training on January 16th. This training will be documented in each employee's annual training record. All new employees including counselors and administrative staff will be trained by the Program Director or Clinical Supervisor on the procedures for completing the ROI form and what information can and cannot be released under 255.5 Confidentiality Code. The ROI/255.5 Confidentiality Code training will be completed during the first full week of employment. The record of this training will be documented in the employee training file. All new employees' training files will be audited by the Program Director or Clinical Supervisor after 30 days of their employment. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to ensure that all disclosures of client identifying information were made in compliance with the limitations established at 4 Pa. Code subsection 255.5(b). Consents in client records also failed to identify what information would be released on each consent to release information.
The finding included:
Ten client records were reviewed on 11/20/2012. Consent to release information forms in six of ten client records failed to identify the specific information to be released. Three of these client records included documentation of releases of client identifying information which exceeded the limitations imposed at 4 Pa .Code subsection 255.5(b).
Client record # 1- This client was admitted on 7/25/12 and last treated on 11/6/12 . Consents to release information in the record signed by the client on 7/25/12 for emergency contacts failed to identify the specific information to be released in the even of an emergency. A consent to release information to a managed care organization for funding was signed by the client on 10/24/12 and failed to document the specific information to be released.
Client record #2 - This client was admitted on 9/11/12 and last treated on 11/2/12. A consent to release information form for a release to a managed care company was signed by the client on 9/11/12 but failed to identify the specific information to be released. Consents to release information forms for emergency contacts signed by the client on 9/11/12 and 9/28/2012 failed to identify the specific information to be released in an emergency. A consent to release information to an area hospital signed by the client on 9/11/12 failed to identify the specific information to be released. Releases were made to DPW in a letter on the following dates without the signed consent of the client: 9/21/12, 10/6/12 and 11/3/2012. These releases to DPW exceeded the limitations on the amount of information that could be released imposed at 4 Pa. Code 255.5(b) by giving the results of drug tests.
Client record # 3- This client was admitted on 7/30/12 and last treated on 11/2/12. A letter containing client identifying information was sent to a third party payer without client consent. The information released exceeded the limitations imposed at 4 Pa. Code 255.5(b) by identifying the types of medications the client was taking and the dosages.
Client record # 4 - This client was admitted on 5/24/12 and was discharged on 7/13/12. A consent to release information for an emergency contact was signed by the client on 5/24/12. This written consent to release information failed to identify the specific information to be released.
Client record # 5- This client was admitted on 5/24/12 and last treated on 8/7/12. The record contained documentation of a signed consent to release information dated 5/24/12. The consent to release information was for emergency contacts but it failed to identify the specific information to be released.
Client record # 7- This client was admitted on 10/25/12 and last treated on 11/14/12. Letters were sent to a third party payer on 6/27/12, 10/4/12 and again on 10/14/12 without the written consent of the client. The information released to the third party payer in those letters included the results of drug tests. This information exceeded the limitations on the amount of information that could be released to third party payers at 4 Pa. Code subsection 255.5 (b).
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
0279
Mandatory training regarding the proper procedure for completing the ROI form with emphasis on what information can be released will be conducted by the program director following the fire safety training on January 16th. This training will be documented in each employee's annual training record. All new employees including counselors and administrative staff will be trained by the Program Director or Clinical Supervisor on the procedures for completing the ROI form and what information can and cannot be released under 255.5 Confidentiality Code. The ROI/255.5 Confidentiality Code training will be completed during the first full week of employment. The record of this training will be documented in the employee training file. All new employees' training files will be audited by the Program Director or Clinical Supervisor after 30 days of their employment.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to document the provision of physical examinations prior to initiating dosing for each client entering Suboxone treatment.
The findings included:
Three client records of clients receiving Suboxone treatment at the facility were reviewed during the November 19-20, 2012 inspection. Facility policy states that "...If appropriateness for treatment has been determined, the physician will proceed with the history and Physical exam ..." During the review of records it was determined that three of three applicable client records failed to document a history and physical examination prior to the commencement of Suboxone treatment.
Client record #1 - This client was admitted on 7/25/12 and last treated on 11/6/12. No documentation of a history and physical examination was included in the client record.
Client record #2 - This client was admitted on 9/11/12 and last treated on 11/2/12. No documentation of a history and physical examination was included in the client record.
Client record #8 - This client was admitted on 7/28/10 and last treated on 11/9/12. No documentation of a history and physical examination was included in the client record.
The need to conduct and document physical examinations prior to the commencement of Suboxone treatment was communicated to the facility director and was not disputed.
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Plan of Correction
M059
NHS Susquehanna Center's Program Director met with both of our psychiatrists and each of them has agreed to do physicals examinations for our clients as needed. We have composed a letter explaining the Physical Examination requirements and have been giving the letter to our existing and new clients. In addition, we are in the process of ordering the additional equipment needed to conduct the physical examinations.Please note, we will not admit any new Suboxone clients until everything is in place for our Doctors to complete the physicals. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to include documentation of a psychosocial evaluation in three of nine client records and failed to ensure that the psychosocial evaluation was complete and evaluative in one other client record.
The finding included:
Ten client records were reviewed during the November 19-20, 2012 renewal inspection. Nine of these client records were due to include documentation of psychosocial evaluations. Three of nine client records failed to include documentation of a psychosocial evaluation. One client record included documentation of an incomplete psychosocial evaluation which was not evaluative.
Client record #2- This client was admitted on 9/11/12 and last received services on 11/2/12. There was no documentation of a psychosocial evaluation as of 11/20/12.
Client record # 3- This client was admitted on 7/30/12 and last received services on 11/2/12. There was no documentation of a psychosocial evaluation as of 11/20/12.
Client record # 7- This client was admitted on 10/25/12 and last received services on 11/9/12. There was no documentation of a psychosocial evaluation as of 11/20/12.
Client record # 8- This client was admitted on 7/28/10 and last received services on 11/9/12.
The psychosocial evaluation in this client record was incomplete because it failed to include documentation and evaluation of a composite picture of the client, the client's support systems and coping mechanisms. Thre was no documentation of the clinical impressions.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
1871
Training regarding the completion of the psychosocial evaluation will be conducted by Outpatient Director on January 16th and/or January 18th. This training will focus on the methodology of completing the psychosocial evaluation and the 4 week time frame for which this task needs to be completed. This training will be documented in the employee's annual training record and will be a required training for all newly hired counseling staff within their first two weeks of employment. The instructor for these trainings will be the Program Director or the Clinical Supervisor. We will also address the time frame in the Policy & Procedure Manual. There are two different time frames indicated in the manual. This will be changed to the longer time frame of 4 weeks. New admissions will be included in the following months chart audit. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations quarterly as required in two of three client records.
The findings include:
Ten client records were reviewed during the renewal inspection on November 19-20, 2012. Three client records were due to include documentation of a case consultations. Quarterly case consultations, in accordance with facility policy, were due in three client records reviewed.
Client record # 3- This client was admitted on 7/30/12 and last treated on 11/2/12. There was no documentation of a case consultation as of 11/20/12.
Client record # 10- This client was admitted on 7/23/12 and last treated on 11/18/12. There was no documentation of a case consultation as of 11/20/12.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
1905
Training on Case Consultations will be conducted on January 18th by the Outpatient Director. This training will address the content of the Case Consult and the time frames for its completion. This training will be documented in each employee's annual training record and will be a required training for all newly hired counseling staff within their first month of employment. Checking for presence and reviewing the quality of the Case Consult will be included in the required monthly chart audits. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document an attempt to follow up on clients in accordance with facility policy in three of three client records where documentation of an attempt to follow up with the client was due.
The finding includes:
Ten client records were reviewed during the November 19-20, 2012 renewal inspection. Three of the client records reviewed were due to include documentation of attempts to follow up on the clients. Three of three client records failed to include documentation of follow up attempts within 30 days of discharge as required by facility policy.
Client record #5 - This client was admitted on 5/24/12 and discharged on 8/7/12. There was no documentation of an attempt to follow up on the client as of 11/20/12.
Client record # 6- This client was admitted on 6/6/12 and discharged on 7/18/12. There was no documentation of an attempt to follow up on the client as of 11/20/12.
Client record # 9- This client was admitted on 2/23/12 and discharged on 6/15/12. There was no documentation of an attempt to follow up on the client as of 11/20/12.
The findings wear reviewed with the facility director and were not disputed. The facility director acknowledged that documentation of the attempts to follow up on clients had been maintained in a separate log book but that the log book was no longer maintained.
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Plan of Correction
1911
Staff #8 and the Administrative Assistants have developed a discharge log that we will use to track all discharges. This log includes the date of discharge, the 30 day past discharge date and a column for documenting the date the follow-up letter is sent. This log will be maintained by the Administrative Assistant and reviewed every Thursday afternoon to determine any discharges who have met the 30 day mark. Follow-up letters will then be sent for those clients within 7 days of their 30 day date. The Outpatient Director will monitor this process monthly.
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